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This is a reminder that as of January 1, 2015, the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) edits are applicable to claims submitted on the CMS-1500 claim form or through the 837P transaction. Please refer to our Commercial and Medicare Advantage claim payment policies on NCCI edits, which are available on our Medical Policy Portal. Select Accept and Go to Medical Policy Online, and then select the Commercial or Medicare Advantage tab from the top of the page, depending on the version of the policy you'd like to view:

• Commercial: #00.01.56a: National Correct Coding Initiative (NCCI) Code Pair Edits;
• Medicare Advantage: #MA00.041: National Correct Coding Initiative (NCCI) Code Pair Edits.

The CMS NCCI tables (Column 1/Column 2) are composed of code pair edits. These code pair edits identify services that are a component of a more comprehensive code or two codes that should not be reported together. Procedure code pairs designated by CMS with an NCCI modifier indicator of 0 (zero) are not eligible to be reimbursed separately when reported on the same date of service for the same member when performed by the same provider. The NCCI edit identified in the CMS NCCI file for these procedure code pairs will be applied by AmeriHealth regardless of the presence of a modifier.

Modifier 25 and modifiers ?X{EPSU} and 59

Procedure code pairs designated by CMS with an NCCI modifier indicator of 1, when clinically appropriate, are eligible to be reported with an appropriate modifier for separate reimbursement. The most frequently used modifiers are 25 and ?X{EPSU} and 59.

• Modifier 25: Modifier 25 is required when a significant, separately identifiable Evaluation and Management (E&M) service is performed by the same physician on the same day of a procedure or other service. For example, if an E&M service was also performed on the same day as an administration of an immunization, the E&M service should be billed with the modifier 25.
  


• Modifiers ?X{EPSU} and 59: Modifiers ?X{EPSU} and 59 are required to indicate that a procedure or service is separate, distinct, or independent from other non-E&M services performed on the same day by the same individual.

Appropriate use of modifiers

For more detailed information regarding the appropriate use of these modifiers, please visit our Medical Policy Portal. Select Accept and Go to Medical Policy Online, and then select the Commercial or Medicare Advantage tab from the top of the page, depending on the version of the policy you'd like to view:

• Modifier 25:
  • Commercial: #03.00.06l: Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the
       Same Physician on the Day of a Procedure or Other Service;
  
  
  
  • Medicare Advantage: #MA03.003a: Modifier 25: Significant, Separately Identifiable Evaluation and Management Service
       by the Same Physician on the Day of a Procedure or Other Service.
  
  
• Modifiers ?X{EPSU} and 59:
  • Commercial: #03.00.08d: Modifiers XE, XS, XP, XU, 59;
  
  
  
  • Medicare Advantage: #MA03.005a: Modifiers XE, XS, XP, XU, 59.

    Note: As communicated in the July 2015 edition of Partners in Health Update, providers should use the more specific ?X{EPSU} modifiers to accurately represent the circumstances that render non–E&M services as separate, distinct, or independent. However, modifier 59 can still be reported if the service cannot be more accurately reported with one of the four specific modifiers. Providers cannot append more than one of these modifiers (i.e., XE, XP, XS, XU, or 59) to a single procedure code. Claims submitted with any of these modifiers may be subject to retrospective review and audit if it is determined that providers are not using them in accordance with the billing requirements in our claim payment policies.

Please refer to the CMS NCCI PTP Coding Edits file for procedure code pair edits and the associated modifier indicators.

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